Hair loss in children

By Liborka Kos, MD

Hair loss in children can be quite distressing to parents, but in most cases is not permanent. Three more common causes of hair loss in children include tinea capitis, alopecia areata and trichotillomania.

Tinea capitis

Tinea capitis: multiple scaly macules and patches without alopecia.

Tinea capitis is a fungal infection commonly seen in children. It has a variety of manifestations, the most common being scaly patches of alopecia. However, sometimes the scale can be minimal, and other times the only manifestation may be diffuse scaling resembling dandruff with no hair loss. Erythema and pustules also may be seen. In "black dot" tinea, hair shafts broken close to the scalp due to fungal invasion are seen clinically as black dots within an area of alopecia. Transmission occurs from humans and animals, as well as fomites (objects such as combs contaminated with fungus).

An "id" or hypersensitivity reaction may be seen with tinea capitis. This is a widespread eruption consisting of tiny, monomorphous, flesh colored or mildly erythematous papules over the trunk, extremities and scalp, which may be pruritic. This reaction is commonly seen after initiation of oral therapy and needs to be distinguished from a drug reaction, which is usually more widespread and more erythematous. An "id" reaction does not require discontinuation of the medication.

Tinea capitis: erythematous plaque with a few pustules.

A culture always should be performed if tinea capitis is suspected. Griseofulvin still is the treatment of choice for tinea capitis. Most experts currently recommend 20-25 mg/kg/d for 6 to 8 weeks (10-15 mg/kg/d if the ultramicrosize form is used). Patients should be told to take griseofulvin with fatty foods, which enhance its absorption. In addition patients should be warned of the potential side effects of gastrointestinal distress, headache and drug rash, although these are not commonly seen. Other effective treatments include terbinafine, fluconazole and itraconazole.

In addition to oral treatment, patients should use an antifungal shampoo such as selenium sulfide or ketoconazole to decrease fungal shedding. They should not share any objects that touch their head (hats, pillowcases, hair care items, etc.). They may return to school as soon as treatment is started. If treatment does not result in improvement of symptoms, siblings should be cultured as they may be asymptomatic carriers.

Alopecia areata

Alopecia areata: multiple oval and circular areas of alopecia.

Alopecia areata affects 0.1-0.2 percent of the population, including infants. It is thought to be an autoimmune disorder where T lymphocytes attack the hair follicles. It is characterized by well demarcated round or oval patches of hair loss that appear suddenly. Scale and erythema are usually absent. The patches of alopecia can be solitary or multiple, and can affect scalp hair, eyebrows, eyelashes and body hair.

The course of alopecia areata is very unpredictable. Some patients develop only a few patches, with spontaneous regrowth within one year. Others continue to develop new patches for a while, while still others (about 5 percent) go on to lose all scalp hair (alopecia totalis). Approximately 30 percent of patients overall will have future episodes. Patients with alopecia totalis have a much worse prognosis, with less than 5-10 percent having complete regrowth. In general, the earlier the onset, the worse the prognosis.

Alopecia areata: two small, well-defined patches of alopecia without scale.

There is no cure for alopecia areata, but therapy may control the condition in some patients. Steroid injections into the scalp are too painful for children but can be effective in teenagers who may be motivated enough to tolerate them. In younger children, potent topical steroids (class I or II) are used. However, there is real potential for adverse effects, such as skin atrophy and systemic absorption. Therefore, these patients should be closely monitored, and steroid therapy only should be used to localized areas of involvement. Minoxidil (Rogaine®) often is added to topical steroid treatment and is most effective for limited hair loss. Other less common treatments involve anthralin cream, contact immunotherapy and phototherapy. No treatment is successful in all patients, and patients with alopecia totalis may not respond to any treatment.

Trichotillomania

Trichotillomania: single linear well-defined area of hair loss with broken hairs of different lengths within it.

Trichotillomania is hair loss due to hair pulling. It usually affects prepubertal children. The child may twirl, pluck, rub or pull on hair, usually when they are alone and in a relaxed environment, such as before falling asleep or while watching television.

The areas of hair loss in trichotillomania often are quite characteristic, with irregular, linear or angular affected areas and accentuation on the side of the patient's handedness. Affected areas never are completely bald, but have residual short, broken off hairs of different lengths.

Trichotillomania may be triggered by a psychosocial stressor, such as the birth of a sibling or a divorce. It usually is self-limited, but may become episodic. Direct confrontation is not helpful. Parents should be reassured. If a stressor can be identified, brief counseling may help overcome the habit.

Trichotillomania: linear, well-defined area of hair loss with short hair of different length in most of the scalp.